Comparative Efficacy of Surgical Approaches for Managing Foreshortened Malleus Handle

ABSTRACT: This narrative review aims to evaluate the comparative efficacy of different surgical approaches for managing foreshortened malleus handle in terms of hearing restoration and surgical success rates. We included studies that reported surgical techniques, hearing outcomes, and graft success rates in patients undergoing type I tympanoplasty, ossiculoplasty, and related procedures. A total of 12 clinical studies met the eligibility criteria. Data extraction revealed that both medial and lateral underlay placements, buttonhole modifications, prosthesis anchoring, and endoscopic techniques produced comparable improvements in air-bone gap closure, with gains ranging from 1.7 to 33.42 dB. Graft take rates varied between 60% and 100%, while reported complication rates ranged from 0% to 50%, the latter in prosthesis anchoring procedures. Technical nuances such as preservation of malleus handle vascularity and specific graft material selection emerged as significant factors in reducing adverse outcomes. Despite heterogeneity in study designs and follow-up durations, no single surgical approach demonstrated a consistently superior outcome. This review highlights the need for standardized reporting of hearing outcomes and graft success, as well as prospective, well-powered randomized trials to address gaps in current evidence. The findings support the use of individualized surgical approaches based on anatomical and pathological considerations for patients with a foreshortened malleus handle. Keywords: Tympanoplasty, Malleus, Hearing Loss, Otologic Surgical Procedures